Use of contraception

Easy access to family planning services and low costs of contraception have been considered the basic elements in the prevention of teenage pregnancies (Darroch et al. 2001a). The use of contraception among adolescents has increased over the years (Meschke et al. 2002).

In the United Kingdom, 75% of early adolescents and 85% of mid-adolescents of both sexes reportedly used effective contraception at their most recent intercourse (Tripp and Viner 2005). In the 1990s the use of contraceptive at last intercourse in adolescents aged 15-19 years ranged between 32.5% and 67.5% in the developed countries (Darroch et al. 2001b). A study in 14 European countries reported that the average age for starting contraceptive use varied between 16.7 and 19.8 years (Cibula 2008). About 50% of the respondents reported having used

contraception during their first coitus. Many teenagers’ pregnancies occur in the first 6 months of sexual activity.

In the USA between 1991 and 1997, condom use increased in adolescents in grades 9 to 12, while the use of birth control pills and withdrawal decreased (Everett et al. 2000). The other US reports showed increases in the use of contraceptives among teenagers and about 3 out of 4 teens used a contraceptive method at their first intercourse (Anderson et al. 2006, Santelli et al.

2006). About 91% of males and 83% of females reportedly used some method at their most recent intercourse in the USA (Abma et al. 2004). A study in the US (Santelli et al. 2006) showed that the risk of pregnancy among girls in grades 9-12 declined by 21% between 1991 and 2003 through use of contraceptive methods.

Inadequate contraceptive use among sexually active adolescents is a worldwide public health problem (Ross et al. 2004). In the Health Behavior in School-aged Children survey, among sexually active adolescents, 11-31% of boys and 2-32% of girls reportedly did not use contraception at the most recent intercourse in 1997/1998 in 13 European countries (Ross and Wyatt 2000). The corresponding figures were 8-27% and 3-32% in 2001/2002 in 30 European countries (Ross et al. 2004).

There was a tendency towards less use of an effective contraceptive method among Danish adolescents in grades 10-12 with no regular partner during the period 1996-2001 compared with the period 1982-1996 (Kangas et al. 2004b). A study in Sweden between 1999 and 2004 showed a tendency over time towards having more sexual partners and using contraception less at first intercourse (Larsson and Tyden 2006). In Slovenia, teenagers around 17 years old had on average 2.2 sexual partners and 14% of them used no effective contraception (Pinter et al. 2009).

6.3.1 Use of oral contraceptive pills

HBSC survey in 2005/2006 among 15-year-old adolescents showed there were wide differences between countries in the use of contraceptive pills at most recent intercourse. OC use ranged from 4% in Spain to 52% in the Netherlands. Among girls, OC use varied from 3% in Slovakia

and Ukraine to 61% in the Netherlands, and among boys from 3% in Romania to 44% in Belgium (World Health Organization 2005/2006).

In Finland, the knowledge of contraceptive methods among teenagers is good (Gissler 2004). The practice of prescribing OC to young Finnish teenagers was adopted in the 1980s (Kosunen 1996). Earlier reports suggest that oral contraceptive use among 16-year-olds increased markedly during the 1980s in Finland. The increase was similar in all parts of the country and in all socioeconomic groups, indicating equal access to contraceptive services (Kosunen et al. 1995). However, our study shows that the use of contraceptive pills more than doubled between 1981 and 1989 and declined in teenagers, especially in the metropolitan area between 1993 and 2003.

The rising trend in adolescent OC use between 1981 and 1989 was primarily due to changes in the pattern of practices in health care. The leveling off of the OC use at the beginning of the 1990s, together with low teenage pregnancy rates, suggests that the need for regular contraception and the use of OC were in balance at that time (Kosunen 1996). Moreover, the rate of abortion decreased by 35% between 1991 and 1995 without a change in oral contraceptive use. Coital activity has increased in Finnish adolescents since the mid-1990s. However, no increase in OC use was found. This probably means that the need for regular contraception was not saturated during the latter half of the 1990s, which may be one reason for the upturn in abortion trends at that time.

To explain why OC use did not increase despite an increase in sexual activity in the late 1990s, reasons other than changes in the health care services also need to be explored. Firstly, it may be related to difficulties in access to health care services. During the economic recession of the first half of the 1990s, several cutbacks were made in public primary health care in Finland, and in services related to preventive care in particular. Absence of these services may reduce access to health care for adolescents who were at risk of pregnancy (Coyne-Beasley et al. 2003, Hagley et al. 2002).

Secondly, a public debate in 1995 voiced concern regarding an increased risk of venous thromboembolism related to the use of third generation OC (Farmer et al. 1997), which led to

reduced OC use in many countries (Iversen and Nilsen 1996, Ramsay 1996). In Finland, discussions in the media were active, too, but reactions were moderate, and, in the short run, Finnish adolescents survived the pill scare with neither a decrease in OC use nor an increase in abortion rates (Kosunen et al. 1997a). Over the next few years, however, the use of OC did not increase as might have been expected on the basis of the increased sexual activity.

The third contributing explanation to be considered is that adolescents used other contraceptive methods than OC in the late 1990s, condoms in particular. Public campaigns to promote condom use were carried out in Finland in the late 1980s after the emergence of HIV (Kosunen 1996). The most remarkable change after the campaigns was that the proportion of adolescents who neglected contraceptive use at first sexual intercourse decreased over the next few years, reflecting an increased use of condoms (Kosunen 1996, Pötsönen 1998). In the 1990s, however, intensified public condom campaigns were not conducted. Probably the perceived threat of HIV also diminished, because the rates of HIV transmission remained low in Finland.

As a consequence, use of condoms decreased in the late 1990s (Gissler 2004).

As a fourth explanation, we might consider sex education in schools, which may have further contributed to seeking services to obtain OC. Sex education in schools has varied in quality and quantity, mostly with reductions in sex education (Kosunen et al. 2002, Liinamo 2005), particularly in the mid-1990s. Moreover, the cost of birth control has an impact on contraceptive use most particularly among adolescents and the cost of oral contraceptives increased markedly during the 1990s (Kirkkola 2004).

Adolescents require intense education and ongoing counseling for initiation and continuation of hormonal contraception. Misperception is common among adolescents and may result in reduced compliance. For instance, many adolescents are concerned that OC pills cause weight gain or acne (Shearman 1984).

6.3.2 Use of novel contraceptive methods

Finnish teenagers rarely use the novel hormonal contraceptives. Only 0.5% of girls aged 16 years and 2.5% of those aged 18 years used the vaginal ring. Use of the transdermal patch was even less common.

In order to be able to seek novel hormonal contraceptives, adolescents need to be aware of them. There is limited information available on the awareness of the vaginal ring and the transdermal patch in adolescents. Among American girls aged 14-21 years (Carey et al. 2007), 52% were unaware of the vaginal ring. Of those who were aware of the method, only 35% had sufficient knowledge. Finnish adolescents may have insufficient knowledge about novel contraceptive methods. We did not gather information on the knowledge of Finnish adolescents about the vaginal ring and transdermal patch.

6.3.3 Emergency contraception

Knowledge of emergency contraception

The School Health Promotion Study in 1996 showed that more than 95% of teenagers knew what emergency contraception is. The proportion of girls who had used emergency contraception increased with age from 2% among girls aged 14 to 15% among those aged 17 (Kosunen et al.

1999). The School Health Promotion Study showed that Finnish adolescents are well aware of EC already many years before sexual relationships are topical; as many as two thirds of the youngest girls aged 12 knew about the method. The present study showed that the proportion of girls who knew about EC increased with age, being 62% among girls aged 12 years and 99%

among those aged 18. Awareness of EC increased significantly over time between 1999 and 2003. However, mere awareness of EC is not enough. There is a concern that although adolescents know about EC, they perhaps do not know how to obtain the pills and how to use them (Mawhinney and Dornan 2004). Such detailed knowledge could not be explored in our mailed survey.

Use of emergency contraception

Our findings demonstrate that only the awareness of EC slightly increased when it became available without prescription (2003-2007) relative to those years when prescription was required (1999-2001). However, the use of EC did not change after it became available without prescription. A small Finnish study in 2002 showed that after making EC available over the counter, the use of EC increased by 62% (Sihvo et al. 2003). A population-based study in USA showed that the use of EC increased by 55% among girls aged 15-19 years after it became

available over the counter (Soon et al. 2005). The number of teenagers requesting EC increased between 2000 and 2001 in Northern Ireland after it became available over the counter, mainly outside local pharmacy opening hours (Mawhinney and Dornan 2004). On the other hand, in the UK in 2001-2002 a significant drop in EC use among girls aged 16-19 years was reported after it became available over the counter (Marston et al. 2005).

Concerning no effect of non-prescription status of EC use, some explanations can be evinced. First, the price of the product is quite high. Perhaps those teenagers most in need of it cannot afford the product. If this is the case, the accessibility of EC has not actually improved despite the change to non-prescription status. Secondly, one of the factors that have been described as limiting more extensive use of EC is the fact that a large proportion of requests occur over the weekend, when family planning clinics and some pharmacies are closed (Lete et al. 2003).